Sunday, December 23, 2007

Happy Holidays

For the holidays--the next issue of Real Life EMS Magazine. (Click on photo for a larger image)

What is really stressful in EMS? Four jobs. Partner problems. No excitement.

While people continue to imply that the stress in EMS is from witnessing horrible trauma, most providers brown out from non-emergency call after non-emergency call.

Regardless of what your stress is from (maybe the holidays?), stay safe, sane and warm this season. Stay healthy to go out and do good tomorrow, and the next day and the day after that. For the greatest gift you can give your patients is to be there and take care of matter how routine that may seem. The greatest gift to yourself is understanding just how wonderful simply taking care of someone can be.

Happy holidays.

Saturday, December 15, 2007

NAEMSE/Massimo part 2

Several days have passed since my initial post about the NAEMSE/Masimo issue. I have certainly had quite a few phone calls and many more emails. One of the most interesting and appropriate calls described Masimo's marketing activities as similar to Invasion of the Body Snatchers.

Picture it. You are one of the few people that hasn't been infected by the Masimo virus. You act like you have...always worrying that one of the Masimo people will see that you haven't been infected...and then eat your head or something.

I made my previous post at 9:02am EST. By 12:00 noon on the same day I had 4 hits on my blog from Masimo in East Irvine, CA. To date there have been 7.

Lets look at what Masimo has done to market (aka push, shove down our throats) their CO-oximetry product.

They developed curricula for EMS providers and distributed it through NAEMSE. NAEMSE sent a letter to its membership recommending CO screening and the educational products developed under a grant by Masimo. Masimo then sent out a mondo press release which was picked up on hundreds of web sites from CNBC, Reuters and market watch to industry news sites.

They developed curricula for firefighters and distributed it through IAFF. I am in the process of obtaining the CD and accompanying paperwork from this mailing. I'll report back on this.

They have a supplement to JEMS this month touting a "Standardized Curriculum on Carbon Monoxide Poisoning." How did this become "standardized?"

They are the only listed sponsor of Note the dramatic scrolling list of news with a bent towards CO poisoning incidents.

The are behind because the sponsor of this site is (sponsored by Masimo) Check out their sponsors page. Grants for CO-oximetry anyone?

They have sponsored most current research on CO-oximetry. They also regularly sponsor sessions at conferences which relate to their products.

They have giant booths at EMS and fire shows. They give away big things. I got a nice duffel to carry my dirty laundry home from JEMS.

While not a smoking gun, it is interesting to note that some links to materials on CO-oximetry are dead links including a link to an IAFF PDF on and the Masimo Carbon Monoxide Training Center at the National Paramedic Institute

Enough already. While companies have the right to push FDA approved devices as much as they want (and make as much money as they want) this borders on exploitative and manipulative. How about taking the money you plan to spend on your next round of pointing out just how necessary and important your product is and REDUCE THE $4,000 PRICE TAG so it can do some of the good you claim it does?

Masimo stock, in its IPO on 8/7/07, was offered at $17.00. At last close it was $40.25 (a 136.8% return in just over 4 months). Despite all the good Masimo may claim to be doing through its lectures, curriculum development and web site sponsoring, let's face it, it is about making money for the corporation.

And back to NAEMSE, the letter was wrong. Period. NAEMSE needs to disclose to its members how much it accepted from Masimo on what dates, who wrote that letter and offer an apology to its membership for this ethical lapse--whether intentional, by oversight or appearance.

Am I ungrateful? No. Practical? Likely. Skeptical? Definitely.

Beware of anyone who takes such lengths to tell us what we need. If it was this important wouldn't it be obvious? Maybe the need to spend $4000.00 isn't as obvious as some would like us to think.

Friday, December 14, 2007

Rampart, we're on the way in with a...

...Cocker Spaniel with a broken leg.

In Michigan, Rampart is the animal emergency clinic and the rig bringing in the dog has lights and sirens...if a bill currently in committee makes it to law.

Siren sought for pet ambulance

Just figured I'd lighten the tone a bit after the NAEMSE/Masimo post. I'll have a follow-up for that in the next few days.

As always, thanks to Paul Maniscalco's listserv for finding some of the most unusual stories in EMS.

Be careful out there.

Monday, December 10, 2007

Has NAEMSE gone too far?

I was doing my daily search of EMS news recently and found a press release on from Masimo touting how the the National Association of EMS Educators made a critical medical announcement:

NAEMSE Letter to Members Warns of Critical and Fatal Implications of Missing the Diagnosis of Carbon Monoxide Poisoning

IRVINE, CA - Masimo (NASDAQ: MASI), the inventor of Pulse CO-Oximetry and Read-Through Motion and Low Perfusion pulse oximetry, today announced the National Association of EMS Educators (NAEMSE) has issued guidance to all its members advocating carbon monoxide screenings for patients presenting with any of the signs and symptoms of carbon monoxide poisoning or suspected exposure. In addition, the organization is advocating enhanced carbon monoxide training programs for all EMS professionals to help improve outcomes and save lives.

In a letter to its membership issued earlier this month, NAEMSE said failing to diagnose carbon monoxide (CO) poisoning during the emergency response efforts may lead to poor pre-hospital decisions, including failure to transport, failure to transport to an appropriate facility, failure to properly treat and failure of the emergency department to diagnose. The consequence of misdiagnosis can often result in returning the patient to a poisoned environment, possibly leading to a fatal outcome. Recognizing that CO poisoning-the most common form of poisoning in the United States-is notoriously difficult to detect, NAEMSE said improved screening and implementation of proper carbon monoxide EMS training programs "can no doubt lead to improved outcomes for patients and potentially save many lives."

Too often, even the most skilled first responders can miss the chance to treat carbon monoxide poisoning early because until now there hasn't been a fast, accurate and noninvasive way to detect elevated levels of CO in the blood. However, with the Masimo Rainbow SET Rad-57 Pulse CO-Oximeter, EMS professionals can easily detect carbon monoxide poisoning on the spot in just seconds with the push of a button, allowing for prompt and possibly life-saving treatment. In addition, Rad-57 can also limit the likelihood of long-term cardiac and neurological damage that can result from non-fatal exposures.

"We see first hand the overwhelming and immediate need for carbon monoxide screening during the first response stage and the importance of standardized carbon monoxide training protocols for EMS professionals as a matter of public safety," said NAEMSE President Angel Burba.

NAEMSE will soon have a new online training program available to all its members, free of charge, on their website The program-consisting of four carbon monoxide modules developed by Dr. Bryan Bledsoe and approved by top EMS physicians and professionals-covers the physiological dangers of CO poisoning, its signs and symptoms, as well as noninvasive methods for on-scene detection of CO in the blood. The modules include downloadable student workbooks, instructor manuals and PowerPoint slides for classroom presentation. Dr. Bryan Bledsoe is an emergency physician, highly regarded as one of the premier educators in the EMS field, and the leading author of numerous EMS textbooks.

Joe E. Kiani, Chairman and CEO of Masimo stated, "NAEMSE's recommendations for proper EMS training and field screening of carbon monoxide poisoning represents an important milestone in the establishment of new protocols for emergency responsiveness and improved public safety. If implemented nationwide, these recommendations will help reduce morbidity and mortality from unsuspected cases of carbon monoxide poisoning."

Coincidentally, NAEMSE's website welcomes Masimo as a new platinum corporate sponsor. Does anyone smell a pay-off? Can you guess who funded the development of the educational materials on the NAEMSE site? Does anyone actually think that someone at NAEMSE wrote that letter? It smells of being written by Masimo and copied onto NAEMSE letterhead--letterhead quoted on sites like (sponsored by Masimo) and healthcare as shameless Masimo ads.

Perhaps most disturbing is the between the lines implication that CO-oximetry may have a routine use to catch those sneaky non-diagnosed cases of CO poisoning.

Remember when we were all incensed when the AHA pushed Amiodarone after the manufacturer built them a new auditorium? How is this any different? And why would MASIMO do this with NAEMSE? Couldn't they get any clinical associations (e.g. NAEMSP, ACEP) to jump on with this sales pitch?

As a matter of fact, letters in Annals of Emergency Medicine are clearly divided on carbon monoxide poisoning and the role of these devices and act as a good representation of the fact that more research and technology improvement is needed.

O'Malley (O’Malley GF. Non-invasive carbon monoxide measurement is not accurate. Ann Emerg Med. 2006;48:477–478) stated:
We prospectively non-invasively measured COhgb on every ED patient. By the end of the second day of the study, we identified 5 false positive pulse co-oximeter readings. Every patient with an elevated COhgb level as described by the pulse co-oximeter had normal serum COhgb as measured with the blood test (100% false positive). The ED staff became distrustful of the pulse co-oximeter and lost interest in recording COhgb readings on every ED patient. We officially stopped the study after recording COhgb non-invasively on 328 patients and identifying 5 false positive COhgb readings

Suner, (Non-Invasive Screening for Carbon Monoxide Toxicity in the Emergency Department is Valuable Selim Suner , Robert Partridge , Andrew Sucov , Kerlen Chee , Jonathan Valente , Gregory Jay Annals of Emergency Medicine- 2007 May (Vol. 49, Issue 5, Pages 718-719) replied in a subsequent letter:
...To discredit a new technology based on 5 cases in a study which was stopped after 2 days is premature. Screening tests will have false positive results. Although confirming false positive results by performing venous co-oximetry has costs associated with it, identifying occult cases of carbon monoxide toxicity may prevent significant morbidity and mortality. With new technology in the field of medicine, frequently there is initial skepticism and growing pains. Similar complaints were evident when pulse-oximetry was first introduced in health care to measure oxy-hemoglobin concentration. It took months if not years before this technology was accepted. Now it is an indispensable tool in our diagnostic armamentarium and arguably a fifth vital sign. It is too early to determine the precise use of pulse CO-oximetry technology in the ED. The scientific community will weigh the data as it becomes available in the literature.

The take-home point in this case isn't in the statistical or research dispute. The issue is clearly stated in the last two sentences of Sumer's letter:
It is too early to determine the precise use of pulse CO-oximetry technology in the ED. The scientific community will weigh the data as it becomes available in the literature.

In short, it's not time yet.

In a position paper, "Critical Issues in the Management of Adult Patients Presenting to the Emergency Department with Acute Carbon Monoxide Poisoning," (October, 2007) the American College of Emergency Physicians states that there were 491 accidental deaths from carbon monoxide poisoning in 1998. Non-fatal poisonings were estimated at 15,000 - 40,000 with an acknowledgment that numbers may be higher because of misdiagnosis.

This post is getting long. Look at the references listed here. Make your own decisions. Here is the Dan Limmer position paper as a conclusion:

1. Masimo appears to have funded every study, education curriculum and press release out there.
2. NAEMSE went too far in issuing the press release and recommendations. I'm OK with the curriculum--generally and as a resource for educators--but am opposed to any statements or veiled implications making CO-oximetry a standard of care at this time. I believe this endorsement timed with platinum sponsorship by Masimo takes credibility away from NAEMSE as a national leadership organization.
3. I question the need for every agency to run out and buy a $4,000 device at this time. It is clearly not a standard of care. The scope of carbon monoxide poisoning cases as noted above does not warrant this designation.
4. In firefighter rehab and suspected carbon monoxide cases it may be useful (duh!) and we didn't need fanfare and press releases to tell us this. Firefighters deserve the best of care. In this area CO-oximetry may be useful and warrant recommendation.
5. The technology is in its infancy and will likely improve to be more reliable. At this time any implication that routine screening of patients is necessary or even suggested is nonsense and may in fact cause unnecessary transport and additional invasive testing.

The end.

Friday, December 7, 2007

Motorist charged in fatal ambulance crash

I have several posts on this blog in reference to an ambulance crash that killed paramedic Allan Parsons and seriously injured EMT/driver Arlene Greenleaf.

Today the Associated Press reported the driver of the vehicle that struck the ambulance was intoxicated and has been indicted for manslaughter and operating under the influence of alcohol at nearly twice the legal limit (0.15% BAC).

TURNER - A 30-year-old Turner man has been indicted on charges of manslaughter and drunken driving arising from an early morning crash last summer in Turner that killed a paramedic while he was tending a patient en route to the hospital.

Christopher Boutin is accused of crashing his pickup truck into an ambulance on Route 4, killing 46-year-old Allan Parsons of Wilton. The ambulance driver and Boutin were seriously injured.

Investigators said Boutin was drunk at the time of the July 5 crash and failed to yield to the ambulance, which had its emergency lights on.

The indictment handed up Thursday said Boutin's blood-alcohol level was more than 0.15, which is nearly twice the legal limit for drunken driving.

My continued heartfelt sympathy goes out to the Parsons family. My sincerest wishes for continued, speedy recovery to Arlene Greenleaf and her family. Although nearly 6 months have passed, the impact of this crash will be ever present for these families over the holiday season.

Thursday, December 6, 2007

EMS Response: Man Colds

How many times have you been called for "emergencies" EMS shouldn't be called for?

Did you ever notice men are weenies when they are sick?

This video addresses both.

Tuesday, December 4, 2007

Accessories make the man...

According to WBNG 12 news, a Johnson City, NY Fire Chief showed up to work last month wearing only a hat and tie. And I mean ONLY a hat and a tie.

JC Assistant Fire Chief Arraigned After Arriving At Work Naked

Apparently this was planned because his stepfather showed up to take photos. The chief was arrested for exposure of a person. Difficult to deny with photos floating around.

Oh, the jokes that come to mind... Wouldn't it be embarrassing to have the charges dismissed for lack of evidence?

I hope the hat and tie were at least Nomex.

Feel free to add your own.

Thanks to Paul Maniscalco's news emails for this story.

iPods for NYPD recruits

NYPD Police recruits will all be issued iPods with training material on them. The iPods will contain laws, procedures and other material to study according to an article published by Reuters today.

"Now a recruit can watch a class on 'search and seizure' while going home on the subway," Police Commissioner Raymond Kelly said in a statement.

In a related story from 2005, NYPD blames iPods for subway robbery surge. I hope the recruits are armed if they study on the subway going to work...

If you would like EMS training material for your iPod I'm proud to say that we saw than need some time ago. Check out the EMT Audio Lecture Series.

Monday, December 3, 2007

Crashes and clashes...both too often in EMS

The Burlington Free Press reported yesterday on a crash that killed a patient and seriously injured the EMT in the patient compartment.

The article, Crash spotlights ambulance risks, is a good review of the issues facing EMTs in the patient compartment. With winter squarely upon us we must all be careful out there.

In the clashes category, the Naples Daily News reports on a county system in transition: Power, politics and money beneath fire merger talks. And EMS is squarely in the middle of the clash. While the devil is in the details when negotiating any merger, success is measured years later by how well a central culture of quality and respect is created from several different agencies.

My best wishes to the patients and providers in Collier County for a successful merger.

Virtual hip replacement...test your skills

Thanks to Libby at the Don't take life too seriously blog I am able to post a very interesting virtual hip replacement site.

See if you've got what it takes...and learn something along the way.